The U.S. healthcare market is in a state of crisis from a financial, clinical, and access perspective. Although numerous discussions in the literature and in the press focus on funding and access to healthcare the market conflict exists in the actual delivery of healthcare. It is not structured to manage patients' access and financial components as part of the process. To illustrate this point a review of key operating statements should be noted:
First, the professional standards association for case managers, “The American Management Society of America,” defines the role of case management as “improv[ing] patient well-being and health care outcomes by supporting the professional development of care managers from a variety of disciplines, practice settings, skill levels and professional capacities.” “Care managers” are further defined as “advocates who help patients understand their current health status, what they can do about it and why those treatments are important” and “catalysts [who guide] patients and provid[e] cohesion to other professionals in the health care delivery team, enabling their clients to achieve goals more effectively and efficiently.” In reality, however, the healthcare market significantly falls short of integrating both clinical and financial case management as a defined process.
An extension of this concept and market conflict issue exists within the mission statement for the Department of Health and Human Services: “The Department of Health and Human Services (HHS) is the United States government's principal agency for protecting the health of all Americans and providing essential human services, especially for those who are least able to help themselves.” This mission statement does not address financial management nor access as a discipline.
In contrast, the mission statement for the Department of Education notes the following: “Establishing policies on federal financial aid for education, and distributing as well as monitoring those funds. Collecting data on America's schools and disseminating research. Focusing national attention on key educational issues. Prohibiting discrimination and ensuring equal access to education.” Access is addressed, unlike in healthcare.
The market conflict exists in the existence tools for the transparent financing of healthcare, clinical integration of, and access to healthcare. It is missing from two critical organizations within our market place on the public side DHHS and from a professional perspective CMSA. So the healthcare market as it exists today although often discussed from an application perspective financial case management as a discipline is not integrated within our delivery system.
The current investigation of Ingenix, a financial data base utilized by many payers, further highlights the market problem of healthcare from a financial perspective. Attorney General Mario Cuomo has identified monetary misrepresentations specifically in the out-of-network private payer world. This is just the beginning of the problem in that the market generating and utilizing financial data is biased and unreliable. The consumer and the healthcare providers do not have access to any reliable method or source of correlating financial data with clinical data. The most significant market problem is that the private payer market views the actual payment of a healthcare service to a provider in contrast to the amount charged back to an employer sponsored benefit plan as proprietary. The unique aspect to this invention is the methodology to create transparency. Transparency does not exist in the private sector. Other market issues with respect to health care waste fraud and abuse can be found in HHS literature available online.
Further compounding the market problem of a lack of transparency are the segments of white collar and organized crime noted in FIG. 1. The ability for ethically challenged market members or entities to execute a theme is significantly higher in an industry in which the concept of monetary transactions is considered proprietary. For example, a payer can contract on what they will pay for a healthcare service on behalf of a plan sponsor. A payer can contract on what it will charge back for the service rendered on a healthcare service. However, neither the plan sponsor nor the provider is privy to the payment transactions. This compounds data analytics on usual and customary pricing in addition to services associated by price, further creating the need for an invention of a transparent data driven decision support system that integrates financial, clinical, and access components.
A need therefore exists for a transparent and reliable decision-support system enabling patients and healthcare professionals to effectively manage and control the healthcare experience from integrated a clinical, access, and financial perspective.